(P-IT-10) Reducing Clerical Errors:  Is There a Better Way?

Clerical errors are always a concern in transfusion medicine where the impact can be especially devastating. As testing volumes increase, staffing decreases, and technologists are tasked with a significant amount of manual labor, the stress level can become overwhelming. In addition, hospitals are merging or expanding which brings in new technologists that might be less familiar with the processes within one’s organization. As a result of an expansion, it was our desire to reduce the opportunity for clerical errors while continuing to focus on patient care. This is a study to consider potential for error reduction by incorporating a data management software system between two hospital facilities.

Study

Design/Methods:

We reviewed our current processes for antibody identification to include manual steps and data entry. We implemented a data management software ImmuLINK 3.1 (Werfen, Norcross, GA) that would digitally pull the master list which includes importing the results, controls, patient name, and medical record # (MR). This ensures the correct strength of reaction was recorded with the correct patient’s name/MR, eliminating the opportunity to grab an incorrect master list or wrong panel lot number.

Results/Findings:

We observed that data electronically sent from our two automated analyzers, Echo Lumena (Werfen, Norcross, GA) included the correct master list, patient name, MR #, controls and patient results. Based on our annual in-house antibody identification of 959 antibodies plus ~5 antibodies at our newly opened facility, we averaged 1.25 antibody panels per patient. The total number of antibody panels perform was ~1,205. Based on 19 potentials for errors (Table 1) with each panel, the number of potential errors is reduced by ~22,895 annually.

Conclusions:

By implementing ImmuLINK 3.1 we have observed a reduction in potential errors and are on target to avoid ~23,000 transcription errors across two facilities by the end of 2024. As both hospitals continue to grow, our testing volumes will likely increase along with the complexity of patients, while our expertise is challenged with more generalists, a tool like ImmuLINK  is very impactful. Anything we can do to decrease our staff’s stress level, reduce potential for errors while increasing our patient care is a priority for both hospitals. We continue to look for ways to reduce technologist stress and improved patient safety. Therefore, we are now considering the option to migrate to an antibody rule out algorithm software.